Walkable Communities Expert Roundtable Report

Association of State and Territorial Health Officials

Table of Contents

Table of Contents ...... 1 Introduction to ASTHO ...... 2 Introduction to Walkable Communities ...... 4 Meeting Summary ...... 5 Expert Recommendations ...... 6 Successes, Challenges, and Current Work ...... 8 Research Gaps and Needs for Promoting Policies and Practices ...... 13 Overall Recommendations ...... 15 Conclusion ...... 16 Acknowledgments ...... 16 Appendix A: Pre‐Meeting Questions ...... 18

Introduction to ASTHO

The Association of State and Territorial Health Officials (ASTHO) is the nonprofit organization representing the state and territorial public health agencies of the United States. ASTHO’s mission is to “transform public health within states and territories to help members dramatically improve health and wellness.”1 ASTHO’s membership includes the State Health Official from every state, territory, freely associated state, and the District of Columbia. ASTHO is supported by a network of 20 affiliates representing an array of state public health agency leaders. Although each affiliate represents a different program director or leader within the state and territorial health agencies, all share a common mission to promote and protect the public’s health. ASTHO’s portfolio includes a broad set of program areas, such as environmental health, infectious disease, immunization, injury prevention, preparedness, performance, chronic disease prevention, and maternal and child health.

The National Prevention Strategy, released on June 1, 2011, aims to guide our nation in the most effective and achievable means for improving health and well‐being.2 The strategy prioritizes prevention by integrating recommendations and actions across multiple settings to improve health and save lives. The strategy identifies four strategic directions and seven priorities. The strategic directions provide core recommendations necessary to build a prevention‐oriented society. The priorities provide evidence‐based recommendations likely to reduce the burden of the leading causes of preventable death and illness. ASTHO is utilizing this framework within the work of the 2014‐2015 President’s Challenge on Healthy Aging, “Living Longer Better Across All Sectors,” addressing recommendations for healthy and safe community environments, empowered people (including caregivers), active living, clinical and community preventive services, injury‐ and violence‐free living, and mental and emotional well‐being.3

ASTHO also supports using a Health in All Policies (HiAP) approach, which is a collaborative approach that integrates and articulates health considerations into policymaking across sectors and at all levels to improve the health of all communities and people.4 Although the concept of HiAP is not new, the term and principles are increasingly being discussed around the country, including in new programs and task forces within health agencies.

Because a multitude of factors beyond healthcare determine the health of communities, public health practitioners, researchers, and policymakers have started to look more closely at the root causes of the public health issues that modern societies face, and are beginning to identify social and environmental circumstances in community environments as substantial contributors. Community design, transportation systems, agricultural activities, access to goods and services, and safe and affordable housing are all examples of environmental conditions that have significant impacts on health. Thus, to fully address the health consequences and benefits of all public projects, policies, and programs and improve population health in the future, diverse sectors need to work together to address complex issues through a HiAP approach.

ASTHO officially began working on HiAP in 2011 through a cooperative agreement from CDC’s National Center for Environmental Health.5 The project’s goal is to educate and empower state health leadership

to promote HiAP through convening a national steering committee and advisory group comprised of state health agency staff and partners, developing policy guides that showcase successful HiAP approaches throughout the nation and exemplary cross‐sector collaboration, and legislative tracking of HiAP‐related bills. Additional details of ASTHO’s work and current resources can be found at http://www.astho.org/Programs/HiAP/.

Background: Burden of Chronic Disease and Introduction to Walkable Communities

Just over half (51.6%) of U.S. adults report meeting the aerobic component of the Physical Activity Guidelines for Americans (>150 minutes per week) and only a third of youth participate in the recommended amount of at least 60 minutes of physical activity daily.6 Promoting walking is a low‐cost way to promote physical activity among all ages and the key focus of “Step It Up! The Surgeon General’s Call to Action to Promote Walking and Walkable Communities.”7 Its purpose is to increase walking across the United States by calling for improved access to safe and convenient places to walk and wheelchair roll, and creating a culture that supports these activities for people of all ages and abilities. In the 2016 Annual Benchmarking Report, 8 researchers found a positive association in communities with policies supporting safe, walkable environments and improved health. Walking presents public health agencies with an important opportunity to partner with other agencies to improve conditions and create such communities. State and local leaders can help highlight the best practice examples of policies and programs that improve walking across a spectrum of urban, rural, and suburban communities.

The concept of “walkable communities” stems from the theory that more livable built environments greatly benefit communities, and that walkability is a marker for livability. According to the Surgeon General’s Call to Action, improving walkability means that communities are created or enhanced to make it safe and easy to walk and that pedestrian activity is encouraged for all people. AARP defines a livable community as “one that is safe and secure, has affordable and appropriate housing and transportation options, and offers supportive community features and services.”9 Walkable and livable communities are likely to see positive impacts from a physical and mental health, social, economic, and environmental perspective. For example, integrating walking into a community’s multi‐modal transportation plan allows for more affordable and equitable transportation for all people, leading to social interaction, increasing physical fitness opportunities, and increased wellness for all. Likewise, the concept of CDC is providing 32 states with “walkability” is both focused and broad, making it a funding to work on the following challenging issue that ultimately impacts many different strategy, including at least one of types of organizations. the following sub‐strategies. Enhanced Strategy 3: Increase Recognizing its importance, CDC is currently funding physical activity access and nutrition, physical activity, and obesity strategies, focused outreach. on providing comprehensive approaches to good health and wellness in communities, supporting partnerships to  Sub‐strategy 1: Create or improve community health, and focusing on preventing enhance access to places negative health outcomes, such as obesity, diabetes, and for physical activity with heart disease.10 CDC’s strategy to increase physical focus on walking combined with activity access and outreach11 is complemented by the informational outreach. goal of creating and sustaining communities with safe,  Sub‐strategy 2: Design accessible walking paths and areas for both recreation streets and communities and transportation purposes. for physical activities.

Meeting Summary

ASTHO held the Walkable Communities Expert Roundtable Meeting on March 19, 2015, in Arlington, Virginia. The agenda revolved around the following three primary goals:

1. Learn from state and local challenges and successes to achieve walkable communities. 2. Identify current areas of research that can support these challenges. 3. Identify gaps and areas for needed research to support state and local community policies to promote walking.

Twenty‐one stakeholders participated in the meeting, including participants from state health agencies (Minnesota and Delaware), the Nashville Area Metropolitan Planning Organization (MPO), academic institutions (Harvard University and the University of Massachusetts Medical School), nonprofits (National Association of County and City Health Officials, National Association of Chronic Disease Directors, American Planning Association, Nemours Foundation, etc.), Smart Growth America, federal agencies (National Center for Chronic Disease Prevention and Health Promotion/Office of Noncommunicable Diseases, Injury and Environmental Health/CDC and EPA), and ASTHO staff. Participants were diverse and included both policy‐level staff who hold management‐level positions, as well as staff with technical and programmatic expertise in various sectors.

Prior to the forum, participants were asked to consider answers to 12 questions that served as a foundation for discussion at the meeting. Similar to the meeting agenda, the pre‐meeting questions centered around four primary discussion points: current work within states and communities, successful strategies and strategies that have not been successful, gaps in research and evaluation, and ways in which CDC, ASTHO, and other national groups can aid in the effort to improve the walkability of communities. The full pre‐meeting questionnaire can be found in Appendix A.

Expert Recommendations

The March 2015 meeting participants outlined the Recommendations: following broad needs to CDC when considering how to assist states and localities in improving the walkability of  Take Data‐Driven Action by communities (not prioritized by order): utilizing data sources from different sectors and  Take Data‐Driven Action: Using consistent, stakeholders. national‐level data—such as the Behavioral Risk  Engage Key Stakeholders and Factor Surveillance System (BRFSS) from CDC and Foster Partnerships between the American Community Survey from the U.S. differing sectors to harness Census Bureau—is a good start. However, these entities’ resources and collecting more resource‐heavy data at the local expertise and create a more level is also valuable because they indicate sustainable and beneficial specific health inequities and challenges among outcome. particular populations. Additionally, public health  Consider Financing and can utilize novel data sources, such as AirSage for Investment as a means to origin‐destination data; Nike Fuel Band and Fuel quantify the expected benefit App, Fitbit, and Apple Watch for physical activity to the community as a whole. data; Lyft and Uber for transportation data;  Recognize Policy Google maps for location data and customized Considerations and mapping; retail data; and general proprietary sources of data. Furthermore, existing data Implications for Sustainability sources may be used more consistently, such as through macro‐level and data within health economic data systems and micro‐level policies paired transportation crash data. Plans for incentivizing with the evidence base to data collection and sharing data are crucial when support impactful policies. involving third‐party entities. Likewise, data may be interpreted differently among stakeholders (e.g., health‐focused, financially‐focused), so it is important to compile data from different sources to get a more all‐encompassing scope of the issues and possible solutions. However, the complexities of data sharing, as well as issues with security and privacy, must be considered when developing plans to share data across sectors.  Engage Key Stakeholders and Foster Partnerships: To create productive partnerships, health officials and coalitions need to be integrated into the built environment processes and have access to the information. Teaching them how to effectively advocate and educate is essential. Similarly, public health needs to integrate the transportation and planning processes, with plans to prepare the workforce and communicate its value. The surgeon general’s call to action highlights the roles that the transportation, land use, and community design sector have on improving walkability in communities. Therefore, creating walkable communities around transit hubs can further encourage walking. New partnerships may include working with technology companies to create a new transportation model to include walkable community aspects.  Consider Economic Benefits: The economic perspective is a critical element of any proposal for funding and resources for a project. Framing the benefits in terms of investment and return‐on‐ investment, as well as the financial benefit over time for the stakeholder and community as a whole, are very important when incentivizing and “selling” the idea to a legislator, business

owner, or any other nontraditional advocate for projects involving infrastructure change and walkability. Furthermore, economic development incentives are useful in capturing stakeholder interest and funding, such as tax breaks. The health argument needs to capture the reality of the community, accounting for differential capacity and outcomes across types of areas (e.g., rural, urban, and suburban). This may be done by utilizing fiscal impact modeling for development project, taking into account the two types of financing: infrastructure and personnel. Additional needs for this approach include ensuring safeguards for funding and the need for more research regarding financing needs (i.e., tying to data needs).  Recognize Policy Considerations and Implications for Sustainability: In contrast to the need for more localized data, macro‐ and micro‐level policies (city and state) are both important when approaching this topic. Changes in chronic diseases, leading to policy change, need to be tracked from a higher level, noting any inequitable implementation of policies and misalignment of priorities across all levels of governance. Furthermore, local grassroots community representatives need to be included in these higher‐level policy conversations so they can help evaluate the expected impact of a policy on the community’s walkability and livability.

Participants also suggested evidence‐based programs and information sharing for CDC.

Evidence‐based Programs and Implementation

• Gaining understanding of current comprehensive strategies is essential for effective implementation.

• Aligning funding decisions with a strategic dedication of resources to specific zones, versus spreading them over a more broad population, maximizes effectiveness and investment.

• Focus should be on initiatives that may produce more substantial data for a particular sector or population.

Information Sharing

• Data and information sharing is critical for implementation from the street‐level to the higher policy level.

• Data sharing is essential to providing a realistic, broad scope of the issue, a population’s needs, and possibilities for solutions.

• Information sharing is also crucial when partnerships are formed so the organizations can better coordinate resources and avoid duplicating efforts.

Successes, Challenges, and Current Work

Successes

Delaware Delaware has a successful initiative called Preliminary Land Use Service (PLUS).12 Through this initiative, public agencies review plans for subdivisions and other projects, review letters from community members, and provide action based on community members’ recommendations. Through PLUS’s work, the state develops comprehensive plans and responds to the needs of communities.

Although not legally required, these projects take health into account, with the addition of trails and walking paths in multiple municipalities. This type of Engage Key Stakeholders and infrastructure change has clear positive health impacts, such as increased Foster Partnerships physical activity in the communities. One meeting participant also used this example to emphasize that stakeholders need to promote new public Even with the absence of a local infrastructure changes so that the community can embrace it. health department, the Delaware

Department of Health and Social In response to a question regarding working with developers to change Services and Community Health infrastructure, and whether they were open or resistant to the idea, a Centers work directly with participant said that developers have been reluctant, at first, to receive nonprofits to localize efforts. new plans that change existing infrastructure, but has seen success since.

The Delaware Department of Health and Social Services and Community Health Centers work directly with nonprofit organizations to localize the efforts, which also encourages other state agencies to work collaboratively. For example, the Department of Health, Department of Transportation, and Department of Natural Resources and Environmental Control, work very closely to take health into account when promoting infrastructure changes.

Minnesota Minnesota works with local public health throughout the state to promote walkability, with many entities supporting the Statewide Health Improvement Partnership (SHIP). Recently, these local public health entities have been working with the Minnesota Department of Transportation (MNDOT) to revive Safe Routes to School (SRTS), with the goals of increasing Minnesota residents’ ability to travel further and use cars less in the Twin Cities area. Securing state‐level funding for infrastructure has resulted in more communities having SRTS travel plans and active transportation plans, widening communities’ access to public transportation, walking, and biking. In addition, MNDOT has also collaborated with Smart Growth America to create a return on investment for walking and biking projects.

Many states are exploring how to reach and engage low‐income populations. Minnesota’s Nice Ride Program and Nice Ride Neighborhood Consider Economic Benefits Program engage community residents, utilizing traditional and nontraditional bike‐share models. The Nice Ride Neighborhood Program and Minnesota is expanding the similar initiatives were developed through a partnership with the Minnesota reach of its public and active transportation options through Department of Health and through CDC’s Communities Putting Prevention collaborations with local and to Work Program in an effort to widen the accessibility of kiosks to state entities to invest in 13 underserved areas. In 2015, these programs have expanded to include underserved communities. working with health systems to prescribe bike shares in areas of the state.

Tennessee The Nashville Area MPO developed its Active Transportation Funding Policy14 with the intent to change the built environment to make active transportation easier and safer to use. The Active Transportation Funding Policy goals are to (1) dedicate funding for active transportation infrastructure and education, and (2) apply scoring criteria that incorporates active transportation indicators. The targeted outcomes for this policy include increased infrastructure for walking (e.g., sidewalks and greenways), increase use of active transportation (e.g., walking, biking, public transit), and increased transportation options for all users (especially zero‐car households).

The Nashville Area MPO developed a two‐fold strategy to increase Recognize Policy funding for active transportation projects: (1) develop project evaluation Considerations and criteria, or scoring criteria, which favor projects that support active Implications for Sustainability transportation, and (2) target Urban Surface Transportation Program funds toward bicycle and pedestrian projects (30%). In the next 25 Nashville’s MPO is working with years, the Active Transportation Program15 is expected to provide other local and transportation approximately $115 million for active transportation infrastructure. entities to implement the Active This policy intervention sets the precedent for active transportation Transportation Funding Policy to infrastructure change given its aggressive and innovative nature, and is provide funding for active transportation in support of the intended to be adopted by transportation planning organizations as a 25‐year Active Transportation public policy regarding the allocation of transportation funds for the Program as an innovative public community’s wider benefit. policy intervention.

Research The Smart Growth America study “Safer Streets, Stronger Economies,”16 Take Data‐Driven Action released in March of 2015, examines the economic and social impacts of 37 projects using data from before and after the projects’ completion. Smart Growth America’s new The data showed increased safety after Complete Streets improvements, report provides the evidence‐base encouraging multi‐modal travel, and improving the affordability of these to support the beneficial impact of types of projects. Complete Streets initiatives on communities.

Challenges: Cross‐Sector Collaboration and Breaking Down Silos

One challenge with implementing infrastructure changes or new practices is not necessarily proximity, but the need for collaboration across different agencies and bringing each to the table to discuss proposed projects. The lack of collaboration can hinder critical data sharing among entities. This

challenge highlights the importance of a HiAP approach, which fosters cross‐sector collaboration and considerations for the built environment that can originate from land use or planning projects.

Local Some local groups, such as Metropolitan Planning Organizations (MPOs), cannot organize, advocate for, or establish performance measures to engage communities in conversations regarding these efforts. Furthermore, MPOs cannot assess health, environment, or other factors relating to transportation due to funding structures. Availability of funding in a particular sector directly influences key decisions. However, local groups’ power comes from the advocacy of community members. It only takes one community member to engage with the right people at the right time.

Federal On the federal side, EPA has broken down silos over the last five years, which has aligned agencies in terms of co‐benefits of work and achievements. However, the coordination of technical assistance is still at the local level. Because of this, it is sometimes difficult to determine who the local stakeholders are for a particular initiative, and the connections between the federal and state agencies are left up to the local community and regional staff to sustain. This challenge highlights the gap in higher‐level policy (state‐ and federal‐level) and local‐level policy (grassroots, community‐level). There is a strong need to set up communities to create processes that roll up to the federal level and then back down to the local level.

Non‐Governmental Agencies For organizations, selecting groups to receive technical assistance requires figuring out which are ready for such assistance and which are prepared to implement the proposed initiatives. Likewise, determining which coalitions have the resolve and resources to take on a particular initiative is often challenging because partnerships among other organizations may be needed.

Furthermore, it is often difficult for stakeholders to focus on funding and return on investment, rather than the community process. Funding criteria is such that if the project does not seem likely to produce positive results, the likelihood of it getting funded is small. Therefore, it is smart to focus efforts at the local level where the funding is broken down.

Different age groups have differing motivations. For example, younger adults and seniors seem to want to walk, but for different reasons. The challenge is to accommodate those interested populations and appeal to a new group (such as middle‐aged individuals) that does not seem to be as motivated. As long as the infrastructure is in place, health messaging may be more effective. However, walking campaigns and health messaging are only effective if the infrastructure is in place to provide that option to individuals. For walkability, places that are heavily traveled by foot or bike, or are generally pleasant, are good places to implement a campaign.

Current Work

Minnesota Minnesota is supporting its SHIP by promoting the following goals: (a) Increase physical activity, (b) increase healthy eating, and (c) decrease tobacco use. The state is engaging local communities through

leadership teams, and stakeholders by bringing them into the planning and implementation process. But as with many initiatives, limited resources (e.g. funding) continue to be a major challenge.

The SHIP is supporting the development of local county surveys that will be asking questions aligned with BRFSS regarding nutrition, physical activity, and tobacco use. By the end of 2015, all counties in Minnesota had access to local data to provide ongoing measurement of the SHIP’s health impact and other health improvement efforts. Local staff worked with community stakeholders and partners such as healthcare systems to complete these community health assessments.

To accompany these community efforts, the departments of transportation and health are co‐leading the development of a statewide pedestrian plan. The effort will build upon the robust engagement that was completed around the Minnesota Food Charter, which was launched in October 2014. Connecting local pedestrian planning efforts, and using the Minnesota Food Charter as a model for a grassroots process, will bring together a health equity focus and engagement with groups that are not usually involved in this discussion (e.g., tribes).

Delaware Delaware has a statewide bike and walk event in which a web‐based surveillance system is used to track minutes of activity and convert them into philanthropic output. The event uses retail outlets whose corporate missions align with community efforts.

Safe Routes to School The Safe Routes for Schools National Partnership is a nonprofit organization that advances policy change and support for healthy, active communities, such as Berkeley, California. One meeting participant mentioned Cycle Kids (Boston) and Cadence Kids (Philadelphia) as leaders in promoting biking among youth and minority populations.

AARP AARP is promoting change in community environments by providing technical assistance programs for communities with local age‐friendly initiatives and a network based on each of the Eight Domains of Livability, features of communities that impact the well‐being of older adults.17

AARP also supports building coalitions to provide support for elected officials, while also empowering community members. These communities create action plans based on community resident feedback and enter a planning and assessment phase every two years. To maintain accountability, action plans are submitted to AARP for implementation assistance every three years. Furthermore, AARP is helping communities develop survey instruments for residents. The Public Policy Institute, through AARP, created a Livability Index18 based on the Eight Domains of Livability to help guide communities in establishing a baseline assessment with various domains.

Macon‐Bibb County, Georgia, was the first to join and submit an action plan for the AARP Age‐ Friendliness Communities Network as of 2012.19 This community was the first in Georgia to be designated as age‐friendly and the first to join as a combined city and county government.20 The action plan has a specific focus on the needs of the elderly, and involves collaboration with developers of new construction and renovation projects to encourage the use of universal design to improve accessibility for seniors. Through this and other action plans, a total of 53 communities, grants were developed to restore and enhance the community’s accessibility to services and programming, and plans for

connectivity between the universities and the downtown transit areas were developed via public transportation and walking/biking trails. Partners within Macon‐Bibb county and others for these action plans include engaged elected officials, volunteer communities, and a volunteer advisory council to report out to the state government, university members, state and local agency staff (health, transportation), and businesses to ensure the economic viability of these plans.

Research Gaps and Needs for Promoting Policies and Practices

The meeting participants discussed research gaps and the need for promoting policies and practices. The following list is a compilation of the research gaps identified by each group. The participants recommended prioritizing the top three items on the list.

Research Gaps

 Although there is adequate data at the national level, BMI reduction is not an appropriate measurement. Therefore, shared policies between local and national levels may be effective in promoting physical activity.  To make the health argument more effective, the focus needs to move from reporting morbidity to encouraging behavior change. Likewise, these messages need to have specific, powerful points relating to the specific community or target population, marketing strategies need to be evaluated and novel strategies need to be developed to appeal to different stakeholders. The fourth goal of the call to action focuses on providing information to encourage walking; in fact, developing effective and consistent messages, and engaging the media and relevant professional to promote walking, can be powerful approaches to promoting behavior change.  More cross‐sector partnerships need to be forged in order to tap into valuable resources and to create effective, sustainable strategies for implementation of walkability initiatives.  Gaining understanding of comprehensive strategies and dedicating resources to specific zones versus spreading over a large population will maximize the investment.  Macro‐level policies should be researched through studies using city and state data for overall impact of an initiative, versus focusing on micro‐level policies. Likewise, there is a need for alignment of policies at all levels of governance.  Development of a process for building leadership for walkable communities is important, as is the building of competencies to better understand the barriers communities are faced with and to sustain future initiatives.  Monitoring and evaluation procedures are essential for determining the overall effectiveness and benefit of an initiative to the community as a whole, including economic, logistical, and social impact measures.

The following is a table summarizing these current projects and the corresponding recommendations:

Minnesota Delaware AARP Safe Routes for Nashville MPO Schools National Partnership and Others Current Work ‐ Statewide Health ‐ Statewide bike/walk ‐ Developed the Age‐ ‐ One of many ‐ Developed an Improvement Program to event utilizing a web‐ Friendliness organizations Active Transportation increase physical activity based surveillance Communities Network involved in a new Funding Policy as and healthy eating, and system to track to provide technical effort to incorporate part of the Active to decrease tobacco use. minutes and convert assistance programs bike clubs into Transportation ‐ Developing a statewide into philanthropic and a peer network companies in an Program, which will pedestrian plan jointly output. for communities with effort to increase increase with the MN ‐ Self‐improvement local age‐friendly physical activity infrastructure for use Departments of Health initiatives through initiatives. among employees of active and Transportation. accreditation the ‐ Created a Livability and promote the transportation by ‐ Identified priority Public Health Index based on the creation of more bike increasing funding populations to engage Accreditation Board. Eight Domains of clubs in allotment and with addressing health ‐ Preliminary Land Livability to help guide communities. opportunities for equity in the pedestrian Use Service (PLUS) communities in ‐ Other peer Nashville. planning process by initiative. establishing a baseline promoters include enhancing the Nice Ride assessment for Cycle Kids (Boston), Programs. livability. and Cadence Kids ‐ Utilizing local staff for (Philadelphia). community health assessments and community events.

Recommendatio X X X n: Data‐Driven Action Recommendatio X X X X X n: Key Stakeholder Engagement and Partnerships Recommendatio X X n: Economic Benefits Recommendatio X X n: Policy Considerations

Overall Recommendations

Based on the discussion at the ASTHO Walkable Communities Expert Roundtable, the following section outlines the recommendations for CDC to consider as it moves forward with any future activities and research related to creating more walkable communities.

General Recommendations

 Convene stakeholders from across sectors (such as the health, economics, and planning) to obtain different perspectives and bring together valuable resources to create and implement more effective, sustainable initiatives that benefit the community as a whole. o For example, the built environment utilizes a business model; therefore, the economic perspective must be represented in discussions regarding plans for implementation. o Highlight the use of a HiAP approach to achieve common goals.  Provide open channels for data and information sharing among stakeholders.  Support policy change, but recognize that it, may only be successful when implemented with both the street‐level policy and high‐level policy perspectives in mind.  Reframe the “health argument” to be specific to each target population and in a way that is easily integrated into each stakeholder’s perspective. Likewise, the messaging should move from focusing on morbidity to encouraging behavior change.

Recommendations to CDC

 Communicate to stakeholders the resources CDC has to support these walkable community efforts.  Facilitate communication between new partners (e.g., Department of Health and Department of Transportation)  Integrate fiscal impact modeling development and utilization into current models for these types of community initiatives.

Conclusion

The ASTHO Walkable Communities Expert Roundtable convened a variety of individuals, from local, city, state, federal, and nonprofit perspectives. Due to this diversity, the roundtable discussion was rich with differing perspectives and examples of work around walkable communities at different levels. Likewise, this group identified potential new partnerships, including those with local businesses, technology companies, city/county/state planners, and national corporations in terms of data sharing, resource allocation, and strategy development. Overall, recommendations to CDC and those interested in furthering the work of building and sustaining walkable communities include data‐driven action, policy considerations from multiple levels of governance, engagement with key stakeholders and forging novel partnerships, and incorporation of the financial and investment components of a walkability initiative. Acknowledgments

ASTHO would like to thank the participants at the ASTHO Walkable Communities Expert Roundtable for their invaluable perspectives and insight. Forum participants included: Geoff Anderson (Smart Growth America), Jeanne Anthony (AARP), Scott Bricker (America Walks), Rochelle Carpenter (Nashville MPO), Angie Cradock (Harvard University), Karin Valentine Goins (University of Massachusetts Worcester Prevention Research Center), Marina Kaplan (Nemours), Richard Killingsworth (Delaware Health and Social Services), Stephenie Lemon (University of Massachusetts Worcester Prevention Research Center), Julie Myhre (Minnesota Department of Health), Kevin Nelson (EPA), Tom Schmid (CDC), Julie Pekarsky‐ Schneider (NACDD), Richard Weaver (APTA), Sandra Whitehead (NACCHO), Elizabeth Whitton (APA), Sara Zimmerman (Safe Routes to School National Partnership , as well as ASTHO staff, including Amanda McQueen, Elizabeth Walker Romero, Lynn Shaull, and Kerry Wyss. ASTHO would also like to thank CDC’s involvement in the cooperative agreement that funded this event and made the forum possible.

Appendix A: Pre‐Meeting Questions

 In your state or the states, communities you work with, what has proven to be a useful strategy to increasing walking rates (policies, programs, initiatives, including environmental changes like walking/bike paths)? o Have you seen other benefits to such policies, programs, etc. (e.g., air and water quality changes; increased school performance for “walking school bus” programs, increased economic activity for complete streets, decreased crime rates, etc.)? o Who needs to collaborate to ensure the policy, program, initiative is successful? Who has been at the table with successful programs in your state? o If you were to go back to the state or community now, are these efforts still in existence?  In your state or state partnerships, what has been a strategy to improve walking that HASN’T worked and/or wasn’t successful? o What policies were missing? Infrastructure? Collaborations or partners that needed to be at the table? o What would have been beneficial to have as information to make this a successful endeavor? o Are there any pieces that are still continuing?  What are research gaps in evaluating such programs? What is public health’s role in this effort?  How do these strategies differ from urban to suburban to rural communities?  What are useful tools to measure the impact of a program or policy on walkability?  What can CDC, ASTHO, and other national groups do to aid in this effort to improve the walkability of communities?

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